Patient
and case report

A
45-year old male was bitten by a snake on the left finger while sleeping. Immediately
after snake bite patient reported difficulty in breathing. He was taken to a
nearby local civil hospital where antivenom management for snake bite was
provided.

After
three hours of clinical observation, the breathing condition of the patient did
not improve. He was transferred to the Emergency Department of the Post
Graduate Institute of Medical Education and Research (PGIMER) where he arrived
approximately 5 hours after the snake bite. On arrival, the patient was
conscious and responded to verbal commands; pupils were dilated, but reactive
to light; blood pressure was 180/100 mmHg; pulse rate was 100/min; ptosis was
present in both the eyes accompanied by weakness in eye muscles. The
patient was kept on mechanical ventilator for next 3 days.

Two
days after weaning of ventilator support, he developed numbness in all the
extremities. Neurological examination revealed hypotonia, weakness in the neck,
jaw and respiratory muscles. Motor power was grade 1.

18
hours after snakebite the patient was stuporous. 20 hours after the snakebite
he went into a state of coma. He had no response to stimuli, fixed dilated
pupil at 5 mm and full ptosis. The patient received 3 vials of specific
antivenom for Bungarus candidus because nocturnal bites causing neurotoxic
signs and symptoms without local necrosis are typical of envenoming bites by
kraits and B. candidus; snakes which are common in the area in which the
incident happened. Thirty hours after snakebite, the patient responded to
verbal commands, while his motor power improved to grade 1. Forty hours
after the snakebite and 32 vials of specific antivenom, motor power had
improved to grade 4. He could open his eyelids easily but slurring in speech
was present. The patient was finally he was discharged from the hospital ten
days after the snake bite. The patient was referred to Speech and Hearing Unit,
attached to the Department of Otolaryngology, PGIMER, Chandigarh immediately
after being discharged from the medical OPD, with a chief complaint of slurring
of speech, resonance problem, reduced loudness and misarticulations. These
complaints were documented by the patient immediately when his consciousness
had improved to verbal output.

Speech
assessment

Franchayís
Dysarthria Assessment tool [1] was
administered on the patient. Detailed assessment revealed that patient had
flaccid dysarthria. The general characteristics found included slurring of
speech, moderate hyper nasality, hypotonia and lowered didochokinetic rate.
There was significant nasal air emission. His breathing pattern was
thoracic-clavicular. Tongue movements and mouth opening were restricted.
Struggle behavior was evident in connected speech. His loudness was reduced.
Dynamic range of pitch and intensity of voice was also found to be reduced.
Frequent gaps of involuntary silence were observed while conversing with the
patient. Paresis and atrophy of musculature, fibrillations and fasciculations
were also evident during the oro-musculature examination. EMG studies were
conducted and 4 paired muscles were recorded because of their antagonistic
functions: 1) Orbicularis oris inferioris and depressor labii inferioris , 2)
mentalis and buccinators. The findings revealed disturbed firing patterns and
well defined abnormalities. These speech symptoms could be attributed to
neurological insult by toxic snake bite.

After
reviewing clinical, neurological and speech findings, a diagnosis of Flaccid
Dysarthria was made which is a rare entity on the account of neurotoxic snake
bite.

Management

The
patient was counseled regarding the nature of problem and prognosis. He was
scheduled for daily speech therapy of 1 hour duration for 3 months. Open mouth
approach was advised to improve his loudness. His speech was worked upon
vigorously to improve his intelligibility. Specific concerns included breathing
pattern changes, limited speech intelligibility due to slurring of speech,
attempts to improve the didochokinetic rate and intensity. There was a
considerable improvement of the patientís speech and the didochokinetic rate of
the patient improved to 1.5- 2.0 per second, which is grossly normal. The
favorable outcome of the present study provides an important example of the
beneficial effects of therapy even for clients with anticipated fair prognosis.
Specific antivenom for B. Candidus, antibiotic drugs, antihypertensive drugs
and tetanus toxoid were given to the patient as autonomic functions such as
tachycardia, and hypertension were observed. The patient received specific
antivenom for Bungarus Candidus after being bitten at 10 hours respectively.
The first clinical response in this case was observed 20 hours after receiving
16 vials; this was in the form of slight movement of fleet phalanxes. At
40 hours after receiving 32 vials of specific antivenom he was able to respond
to verbal commands, motor power changed from grade1 to grade 4 with 100%
elevation of eyebrows from full ptosis. The patient had spontaneous opening of
eyelids at 90 hours after receiving specific antivenom therapy. The patient was
discharged later on day ten.

Discussion

This
case was found worth reporting as it was a very rare occurrence. Similar cases
probably go unnoticed as the primary concern is basic physical recovery, speech
is a later concern. Although many studies were found in European and American
countries [2] but very few studies are presented in Indian
literature, that too from speech perspective [3]. Although
the recovery rate is high in those patients who received specific antivenom
therapy, the speech symptoms often persist. Speech problems have been
considered at secondary level and not given equal importance. The patient has
been coming for regular speech therapy for the last three months and there has
been a marked improvement in his articulation and loudness. Moreover, the
overall speech intelligibility of the patient has improved to a great extent.
Even though the paresis of lower motor neurons, motor and respiratory muscles,
neurotoxicity of the venom include the autonomic dysfunctions, the patient
showed tremendous improvement in his speech and articulatory proficiency.

Conclusion

Returning
of near normal speech after receiving speech therapy showed the importance of
timely speech therapy intervention. Clinical response includes returning of
good speech with improved loudness and intelligibility.

Authorís contribution

DV:
helped in diagnosing and managing the speech problems of the patient. He
contributed to the write up of the manuscript. S: worked on the case and
managed it with his full expertise. Collaborated with the neurology department
and collected all information necessary for preparing the manuscript. DG:
gave suggestions regarding the various neurological aspects of speech and
helped in writing the manuscript. MM: provided all the necessary
information as far as neurological aspects were concerned in this case.
Moreover, he reviewed the final manuscript and gave his expert comments. NP:
provided all the necessary information as far as laryngologic aspects
were concerned in this case. Moreover, he reviewed the final manuscript and
gave his expert suggestions.

Competing interests

The
authors declared they have no competing interests

Acknowledgements

Permission
was taken from the patient for writing this case. We highly acknowledge his
gesture.